Sandhills Center
1915 (b)(c) Medicaid Waiver
Implementation
Presented by
Sandhills Center
What is a
1915 (b)(c) Medicaid Waiver?
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A combination of two sections of the federal Social
Security (Medicaid) Act.
Section 1915(b) is called the Managed Care/Freedom of
Choice section
 This Section provides the US Health and Human
Services Secretary authority to grant waivers that
allow states to implement managed care delivery
systems, or in other words, limit choice of providers
under Medicaid.
Section 1915(c) defines a set of waivers called Home and
Community-Based Services.
 This section provides the Secretary the authority to
waive Medicaid provisions in order to allow long-term
institutional care services to be delivered in community
settings. In North Carolina the CAP-I/DD waiver is an
example of this.
What is a
1915 (b)(c) Medicaid Waiver? (cont.)
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States may choose to use both sections to provide a
continuum of services to a defined population. In
North Carolina, this population is people with mental
illness, intellectual/developmental disabilities, or
substance abuse disorders.
Within this combination, states may provide long-term
care services using managed care tools while limiting
the pool of providers according to a set of criteria
which include qualifications and access.
34 states use waivers for managed care behavioral
healthcare plans.
States must abide by federal rules established for
operation of these waivers.
Components of a 1915 (b)(c) Waiver
Managed Care Organization
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Capitation – provides local flexibility and control of
resource $$ funding.
Payor of claims – ensures that funds are spent in
accordance with authorizations.
Rate setting authority – allows the waiver entity to
adjust rates according to local provider conditions.
Closed Provider Network – allows for competition
and choice while right sizing the marketplace; ensures
health of providers.
Utilization Management – give the waiver entity the
tools to ensure consumers receive both the appropriate
service and amount to meet their needs.
Care Coordination – an important activity that
directly intervenes to direct consumers to the right
level of care.
Questions ?
Sandhills Center’s Transition to a Local
Management Entity/Managed Care
Organization (LME/MCO)
What will remain the Same? What will be improved?
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Sandhills Center will implement the
Medicaid Waiver effective July 1, 2012.
Customer Services will continue to have:
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Toll-free telephone contact 7 days a week, 24 hrs
per day.
Increased Customer Services staff well equipped
to answer questions and give immediate
responses.
CONSUMER AND FAMILY ADVISORY
COMMITTEE (CFAC)
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The Sandhills Center Consumer and Family Advisory
Committee recognizes the contribution of members and
their abilities and perspective through advocating for
improvements in quality care; identifying barriers, service
gaps and needs as they arise and recommending possible
solutions.
The committee serves as a liaison between Sandhills
Center and the community. It is comprised of members
and their families who reside within Sandhills Center
geographic area. To obtain further information you may
contact the Sandhills Center CFAC staff liaison about this
committee… Toll free at 1-800-256-2452 as noted on our
Sandhills Center Website www.sandhillscenter.org
Customer Service Handbook
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A Customer Service Handbook is available to all of our
members. It is posted on the Sandhills Center
Website. Handbooks can be obtained by calling our Customer
Service Section @ 1-800-256-2452. The Handbook contains
information pertaining to 1915 (b) (c) Waiver Services including
for the entire Sandhills Center MH/IDD/SA population.
The Handbook includes the following information:
• How Requests for Services are Prioritized
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Care Coordination Functions/ Community Guide Functions
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Emergency/Crisis Situations and Preparations
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Description/lists of Services/Assessment Tools and Practice
guidelines
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Screening, Diagnosis and Treatment/Funding for Services
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Person Centered Planning/Access to Services
Customer Service Handbook (cont.)
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Clinical Triage & Referral Process/ Peer Support/TBI
services
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The Provider Network/Types of Providers/Location
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Privacy Information/Human Rights/Civil Rights
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Complaint/Grievances and Appeals
Process/Complaint form
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Appeals Process regarding Medicaid and NonMedicaid Service Decisions
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Advocacy/Information/Groups
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Informational Websites
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List of Homeless Shelters/CFAC/Cultural
Competence
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TTY Relay Calls/SHC Organizational
Structure/Advance Directives
Care Coordination
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Care Coordination
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Under the managed care environment of the 1915(b)(c)
Medicaid Waiver, a number of activities that were
previously associated with the provider service - case
management, become the responsibility of the Local
Management Entity (LME)/Managed Care Organization
(MCO).
The LME/MCO refers to these functions as “Care
Coordination”.
Care Coordination is not a service. It is an outcomes
driven function used in managed care systems.
This is consistent with the way care coordination is
provided in other healthcare settings across the country
and is similar to the model used by Community Care of
NC (CCNC) for the management of high risk consumers
served by Medicaid in primary care practices.
Care Coordination (cont.)
Care Coordination Continued
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Care Coordination in the Medicaid Waiver is
specifically focused on the unique needs of persons
with mental health, substance abuse, and
developmental disabilities and is designed to serve
high need individuals and assure that vulnerable
populations have access to needed care.
Care Coordinators are community based and
provide hands on assistance to individuals.
The LME/MCO must meet extensive accountability
standards, data reporting requirements, and must
exercise risk management responsibilities. Under
Managed Care, LME/MCOs are fully accountable for
the quality and compliance of the Provider Network.
Care Coordination (cont.)
Care Coordination Continued
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Care Coordination in an LME/MCO provides the
following supports to consumers:
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Education about all available MH/SA/DD services
and supports, as well as education about all types
of Medicaid and state-funded services.
Linkage to needed psychological, behavioral,
educational, and physical evaluations.
Development of the Individual Support Plan (ISP)
or Person Centered Plan (PCP) in conjunction with
the recipient, family, and other all service and
support providers.
Monitoring of the ISP, PCP, and health and safety of
the consumer.
Coordination of Medicaid eligibility and benefits.
Role of MH/SA Care Coordinator
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Identify people that are in need of MH/SA
Care Coordination.
Ensure that people with the greatest need
get connected with a CABHA.
Linkage to needed MH/DD/SA resources
(including ensuring provider choice).
Review the Person Centered Plan and
determine along with the provider if and
when the plan should be changed.
Make suggestions for enhancing a
person’s care based on clinical guidelines
adopted by the LME/MCO.
Role of MH/SA Care Coordinator
(cont.)
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Ensure that a person with high behavioral health
problems have both their behavioral health and
physical health problems addressed.
Assist in discharge planning when a person
receives treatment via inpatient care.
Ensure that services in the service plan are being
provided.
Ensure that the health and safety of a high risk
individual is considered in the plan.
Open communication with Community Care of
North Carolina Management teams.
Questions ?
I/DD Care Coordination for Individuals
Not Enrolled in the Innovations Waiver
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I/DD consumers not enrolled in the
Innovations program will receive
care coordination.
Care Coordinator will:
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Complete or arrange assessments to
identify support needs
Develop ISP
Monitor services
Supports Intensity Scale
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Takes the place of the NC-SNAP.
Requirement for all I/DD consumers.
Designed to measure the pattern and
intensity of supports an individual with
intellectual/development disabilities
requires to be successful in community
settings.
Occurs during the initial assessment,
every two years, or as needs change.
State Funded Services
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Are services that are paid with State
appropriated funds.
State funded services are not part of any
entitlement program (such as Medicaid).
State funded services are dependent upon
the availability of funding Sandhills Center
receives from the State.
We adjust the benefit plan to reflect
changes in funding availability.
State Funded Services (cont.)
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Personal Assistance
Developmental Therapy
Respite
Supervised Living
ADVP
Supported Employment
Developmental Day
Long Term Vocational Support
TBI (Traumatic Brain Injury)
Group Living
Regular Medicaid Services
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Outpatient Therapy
Psychiatric Services
Medication Management
1915 (b)(3) Medicaid Services
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B-3 Medicaid services allows for additional
consumer support.
B-3 services are dependent upon the
availability of funding Sandhills Center
receives from the State.
Respite
Supported Employment
Long Term Vocational Support
B-3 Deinstitutionalization Services (B-3
DI Services)
Community Guide
ICF/MR Services
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Sandhills Center will approve all ICF-MR services for
consumers from the Sandhills Center region.
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This will include Sandhills Center consumers in State
Developmental Centers and community ICF-MR
placements.
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Psychological evaluations and the Sandhills Center
ICF-MR Treatment Authorization Request form will be
completed by a Sandhills Center network provider.
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Sandhills Center IDD Care Coordination services will
ensure completion of the Level of Care Eligibility
Determination Form.
Questions ?
The Same but different…
The Community Alternatives Program for
Individuals with Intellectual and/or
Developmental Disabilities (CAP-I/DD)
and
North Carolina Innovations
Are
Home & Community Based Services (HCBS)
Waivers
Under
Section 1915(c) of the Social Security Act
NC Innovations
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As of July 01, 2012 the NC
Innovations Waiver will be
implemented.
CAP-I/DD waiver will not exist in
the Sandhills Center catchment
area.
Transition Plan from the CAP-I/DD to
the NC Innovations Waiver
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All participants currently on the CAP-I/DD waiver will
transition to the NC Innovations Waiver.
All Services currently used under the CAP waiver (or
equivalent service) are available in the NC
Innovations waiver.
The NC Innovations Waiver is a Comprehensive
Waiver.
ISP Transition-for current CAP-I/DD waiver
participants to NC Innovations, the current approved
Person Centered Plan will be accepted in the NC
Innovations waiver until the next annual Individual
Support Plan (ISP) development at the participant’s
birth month.
Transition Plan from the CAP-I/DD to
the NC Innovations Waiver
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Comprehensive and Supports Waiver participants
will use their current CAP-I/DD budgets to ensure a
seamless transition into the NC Innovations waiver
until the SIS assessments and Support Needs Matrix
category budgets can be developed by DMA.
Level of Care Transition-for current CAP-MR/DD
waiver participants to NC Innovations, the eligibility
determination will be accepted in the NC Innovations
waiver until the next annual Re-evaluation of
eligibility at the birth month.
Transition Plan from the CAP-I/DD to
the NC Innovations Waiver
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Individuals/families will be contacted by a
Care Coordinator to discuss services prior
to transition.
Including meeting with the individual’s PCP
treatment team.
As of July 01, 2012, your current TCM
provider will not be responsible for
treatment plan development and
monitoring of services.
CAP-I/DD to NC Innovations
Services with the same Name
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Day Supports
Home Modifications
Personal Care Services
Residential Supports
Respite Care
Specialized Consultation Services
Supported Employment
Vehicle Adaptations
CAP-I/DD to NC Innovations
Current Services with Different Names
CAP-I/DD
NC Innovations
Personal Emergency Response
System (PERS)
Assistive Technology Equipment
& Supplies
Specialized Equipment & Supplies
Assistive Technology Equipment
& Supplies and/or Individual
Goods and Services
Behavioral Consultation
Specialized Consultative Services
or Crisis Services- Behavioral
Consultation
Crisis Respite
Crisis Services-Out of Home
Crisis
Crisis Services-Primary Crisis
Response
CAP-I/DD to NC Innovations
Current Services with Different Names
CAP-I/DD
NC Innovations
Individual Caregiver Training and
Education
Natural Supports Education
Long Term Vocational Support
Supported Employment
Enhanced Personal Care
In-Home Intensive Support
Community Component of Home
and Community Supports
Community Networking
(use only for activities provided
as individualized Day Programs)
Home Component of Home and
Community Support
In-Home Skill Building
CAP-I/DD to NC Innovations
Services Not Available Under Innovations
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Adult Day Health Care Services
Transportation
Enhanced Respite Care – crosswalk to
standard Respite Care as only option
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Home Supports
- similar service is In Home Skill
Building, In-Home Intensive Support and Personal Care
Participant needs to contact the Care Coordination
Department at Sandhills Center with any issues.
NC Innovations
New Service
Community Guide
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New service to individuals
transitioning from CAP-I/DD
(optional service)
Role of Community Guide
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Advocacy Support-includes education
Development of community resources
Assistance with linkage to needed
supports
Assistance with Individual and Family
Directed Service options
Note: Care Coordinators will not perform functions of
Community Guide
Service Options through
Innovations
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Traditional Provider Directed Option
Individual/Family Direction Option (Self
Direction)-Agency with Choice (Managing
Employer)
If the person tries an option and is not
satisfied they can change.
The person has the flexibility to direct only
the services that they choose.
Services that can be
Individual/Family Directed
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In-Home Skill Building
Personal Care
In-Home Intensive Support
Natural Supports Education
Community Networking
Respite
Supported Employment
Community Guide
Individual Goods and Services
NC Innovations
Targeted Case Management
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Targeted Case Management does not
exist as a service in 1915 (b)(c)
Managed Care Waivers
Care Coordination replaces many of
the functions of Targeted Case
Management
Role of Care Coordinator
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Educating participant/family/providers
about services/supports, waiver
requirements, eligibility,
appeals/grievances, processes, options
Assessment of support needs
(completing, arranging for, obtaining)
Complete Risk Assessment, Level of Care
Assessments, Community Guide Need
Survey
Role of Care Coordinator (cont.)
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Linkage to needed MH/DD/SA resources
(includes ensuring provider choice)
Facilitation of Planning/Plan Development
Monitoring plan implementation, including
health and safety
Medicaid eligibility coordination
Open communication with Community
Guide as applicable
Limits on Services
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Cost Limit: Upon admission and
with continuing eligibility:$135,000
annually.
Use of one waiver service: must
use one waiver service per month.
Innovations waiver will have service
limits as on the CAP-I/DD waiver.
Care Coordinators will discuss
service limits at transition meetings.
Relatives Providing Services
Relatives Defined
For Adult Participants age 18 and older:
 Parents
 Step-parents
 Adoptive parents
 Legal Guardians
 Other adults that live in the natural home
as the participant
Relatives Providing Services
Service Options
For Adult Participants age 18 and older:
 Community Networking
 Day Supports
 Personal Care
 In-Home Skill Building
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In-Home Intensive Supports
Residential Supports
-Only in out of home placements
Relatives Providing Services
Conditions of Employment
For Adult Participants age 18 and older:
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Limitations in Individual/Family Directed Supports
options
Consents to monthly on-site monitoring of services
Service Limitations
-Typically no more than 40 hours
of service per week provided between
all relatives who reside in the home
or
-7 daily units per week
Prior authorization for provision of services by a
relative or Legal Guardian is required
Spouse of participant may not provide services
Relatives Providing Services
Child
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Participants under 18 years of age
-No adult living in the natural
home may provide periodic
services
-Parents, step-parents, and/or
adoptive parents may not
provide services
-Legal Guardians may provide services
in licensed residential placements
Questions ?
Reference Materials
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1915(b) State of NC MHDDSAS Plan renewal April 1,
2011 – March 31, 2013
1915(c) NC Innovations Waiver Draft dated 04/01/2011
Current DMA Clinical Coverage Policy #8M
Proposed DMA Clinical Coverage Policy #8M
Manual for the 2008 CAP-MR/DD Comprehensive Waiver
PBH Introduction to 1915 (b)(c) Waiver Operations
Presentation May 2011
House Bill 916-Statewide Expansion of 1915(b)(c)
Waiver
Western Highlands Network on NC Innovations
Transition November 2011
Presenter Information
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Dorinda Robinson, MSW, LCSW, Care
Coordination Director
Al Gainey, LPC, I/DD Program Director
Tena Campbell, MSW, Innovations and
I/DD Clinical Director
Gene McRae, Customer Service Director
Mike Markoff, Customer Service
Coordinator
Additional Questions?
Call Customer Services
1-800-256-2452
Provider Help Desk
1-855-777-4652
Community Education Advisory Group
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Ron Huber
Anthony Pugh
Carol DeBerry
Lori Richardson
Andi Chaney
Cynthia Curtis
Harold Pearson
Marcy Petti
Mary Sullivan
Nancy McNiff
Wendy Russell
Rita Pena
Julia English
Tiffany Arnold
Debbie Watson
Susie Roeder
Gene McRae
Mike Markoff
Al Gainey
Tena Campbell
Jordan Medlin
Robert Grooms
Pam Morgan
Victoria Whitt
CFAC Chair
CFAC Co-Chair
CFAC Member
CFAC Member
SS&P
Bethany House
Samaritan Colony
The ARC of NC
SS&P
Sandhills Center Board of Directors & Monarch Family Advisory Committee
The ARC of Moore
Parent
ResCare
ResCare
The ARC of NC
Monarch Family Advisory Committee
Sandhills Center
Sandhills Center
Sandhills Center
Sandhills Center
Sandhills Center
Sandhills Center
Sandhills Center
Sandhills Center
Sandhills Center Community Education Advisory Group
I-DD Subcommittee
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Lori Richardson
Andi Chaney
Marcy Petti
Wendy Russell
Al Gainey
Tena Campbell
CFAC Member
SS&P
The ARC of NC
The ARC of Moore
Sandhills Center
Sandhills Center
Sandhills Center Consumer and Family Advisory Committee
Flyer Distribution and Forum Site Volunteers
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Ron Huber
Ron Unger
Elaine Hayes
Carol DeBerry
Lori Richardson
Michael Ayers
Anthony Pugh
Irma Robledo
Marianne Kernan
Chris Laughlin
Loida Colonna
Stephen Cohen
Debra Collins
Ashley Wilcox